Saad - Osteoarthritis part 2 Flashcards by amanda kastel

aside from GI , name 2 other potential NSAID toxicities

Cardiovascular
renal

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how do NSAIDS have CV toxicity concern

they can increase blood pressure and exacerbate congestive heart failure

seen with all NSAIDS used chronically (naproxen may be least harmful)

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chronic use of NSAIDS have increased risk of CV events

which NSAID may be the least harmful in this regard?

naproxen

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Explain the risk/benefit of NSAIDS and CV toxicity

the overall risk is small – however if it does happen could be life threatening
benefit is relief of pain

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NSAIDS are contraindicated before and after _____ surgery

CABG

coronary artery bypass graft

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NSAIDS being used with what 2 classes of drugs has renal toxicity concern? explain

NSAIDS + ACE inhibitors or diuretics

can reduce blood flow to kidneys and cause toxicity

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name a sulfonamide NSAID that must be avoided in patients allergic to sulfa

celecoxib

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true or false

NSAIDS should be avoided in the renally impaired

true

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name 2 hypersensitivity reactions of NSAIDS

rash, bronchospasm

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*** what is the NSAID only approved for SHORT TERM USE?
WHY?
how long?

ketorolac

less than or equal to 5 days

it is extremely potent – thus has the most GI, renal, CV side effects

give to patients requiring opioid-like pain relief

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NSAIDS with _____ and ________ cause more GI side effects

a long half life
extended release dosage form

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name the 3 systems that are a concern for toxicity when taking NSAIDS

GI
CV
kidney

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explain the NSAID + ASA (aspirin) interaction

NSAIDS block COX1 – aspirin cant access

ONLY if NSAID is taken before aspirin

NSAIDS block the antiplatelet effects of aspirin (if taken before) – have reversible and variable antiplatelet effect

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**important:

when should ibuprofen and aspirin be taken to avoid interaction

take aspirin 30 mins BEFORE ibuprofen

if pt already took ibuprofen, have to wait at least 8 hours to take the aspirin – so that COX1 isnt blocked by it

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true or false

opioids are 1st line and used for initial management of OA pain

false

risk of abuse – OA is chronic
not used for initial management

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when may opioids be useful in OA patients?

those who dont get much relief from NSAIDS, aspirin, intra articular injections or topical therapy

(or they cant tolerate side effects)

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true or false

data on opioids fails to demonstrate a clear benefit for chronic pain

true

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do opioids and tramadol have the same side effects?

yes - but lower abuse potential and tramadol less potent

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tramadol is contraindicated during or within 14 days following _________ therapy or other medication with __________ activity.
why?

MAO inhibitor
or other med with serotonin activity

risk of serotonin syndrome

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true or false

tramadol is available as a stand alone and with acetaminophen

true

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true or false

tramadol requires dose adjustment in renal failure

true (max 200mg a day)

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max daily dose tramadol with normal renal function

400mg

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what DEA class is tramadol

schedule 4 control

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name some tramadol adverse effects

CNS depression
drowsiness, dizziness
constipation
resp depression
tolerance
addiction

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tramadol should be given with caution if the patient is taking....

meds that lower the seizure threshold

true or false duloxetine and tramadol should be given with caution

true serotonin syndrome risk

name 2 topical OA therapies

capsaicin diclofenac (voltaren)

TRUE OR FALSE topical OA therapies cannot be used in combination with other pharmacologic therapies for OA

FALSE - they can

name an advantage that topical therapies have over oral for OA

ppl unable to tolerate oral NSAIDS bc GI/renal/cardiac side effects can take

How does capsaicin work to reduce pain

depeletes substance P - neurotransmitter

in which OA areas are capsaicin most effective? in which joint is it least effective?

most effective in hands and knees not very for hip

in which area should capsaicin definitely not be applied

any mucous membranes - severe burning

is capsaicin recommended for initial management of OA pain?

no - but can be used if other treatments fail

what is an advantage of capsaicin over other pain relief OA therapies

no systemic adverse effects

how long does capsaicin take to give analgesic effect after applied?

3-5 days *will burn initially may take several weeks for MAXIMAL effect

how many times a day is capsaicin applied

3-4 times

explain how you would counsel a patient on how to use capsacin

wear gloves and avoid cutaneouos/mucus membranes may take 3-5 days to work, will burn at first, up to several weeks to see max effect

are topical NSAIDS systemically absorbed?

minimal-none

the ACR strongly recommends topical rather than oral NSAIDS for which age range?

greater than or equal to 75 years

the efficacy of topical NSAIDS has been observed in which 2 kinds of OA?

knee and hand

diclofenac gel/solution/patches typically requires ____ times daily dosing

name an NSAID that can be compounded to be topically applied

ketoprofen

what was the theory of using hyaluronic acid in OA patients

thought was that they would act as a shock absorber in synovial fluid and provide elasticity -efficacy is questionable and response is very variable

ACR conditionally recommends against the use of intrarticular hylauronic acid in ______ OA and STRONGLY recommended against it in ____ OA

knee hip

what is an advantage of IA hyaluronic acid over other agents

avoiding systemic side effects

many hyaluronic acid injections are contraindicated in patients with what allergy?

avian (bird)

besides patients with avian allergies, where else is IA hyaluronic acid contraindicated

in an infected joint space

explain the clinical evidence of hylauronic acid in OA patients

cannot be confirmed response seems to be variable, efficacy is questionable. may just be placebo effect question of whether the mass influences efficacy

what are some adverse effects of intra articular hyaluronic acid injections

local pain, itching, joint swelling, ecchymosis (bruise)

are intra-articular STEROIDS beneficial in OA patients?

yes - for acute flares, effusion, and severe OA

TRUE OR FALSE oral and intra-articular steroids have use in OA patients

FALSE - only intra-articular

as mentioned, intra-articular steroid injections can be used in OA patients in cases of localized effusions what is a consideration with this?

the fluid must be aspirated before injecting if there is an effusion

repeated intra-articular steroid injections may cause.....

bone loss and/or tendon rupture

the dose of intra-articular steroid injections depends on what

the size of the joint

localized side effects of intra-articular steroid injection

localized inflammatory reaction

what would you tell a pt getting intra articular steroid include how long it may take to work and what to avoid

should begin in 2-3 days and last 4-8 weeks avoid straining the joint a few weeks after injection

name some SYSTEMIC side effects of intra articular steroids

edema, inc BP, hyperglycemia, dyspepsia, hypercorticolism

does the ACR recommend glucosamine/chondroitin for OA?

ACR really only mentions chondroitin as conditionally rec for hand OA but strongly rec AGAINST in knee/hip. but it's mainly sold as a combination product with glucosamine

how is glucosamine/chrondroitin thought to work in OA patients

it stimulates proteoglycan synthesis from articular cartilage -- help maintain hydrostatic pressure depsite the compressiong pressure glucosamine - "building block" for cartialge chondroitin sulfate "water magnet" in cartilage

what is an advantage of glucosamine/chondroitin over oral NSAIDS

can avoid the GI/CV systemic side effects in pts predisposed to these -- safer

explain the effectiveness of glucosamine/chondroitin over an NSAID like celecoxib

in a study, combo was not better than celecoxib at relieving pain

name some AE of glucosamine/chondroitin

mild GI discomfort like gas and bloating

________________ should be avoided in SHELLFISH ALLERGY

glucosamine

__________ should be avoided in cattle, shark, pink allergy

chondroitin

if glucosamine/chondroitin will show effect, how long will it take

4-8 weeks

why are glucosamine/chondroitin studies not reliable (aside from placebo effect)

they only measure patient symptoms and no changes in morphology

what are DMOADS

disease modifying OA drugs

name a supplement that may be just as effective as oral NSAIDS in OA patients

turmeric